Contractor Authorized Signatory Listing for Sole Proprietors Form.pdf
PDF 220 KB Posted
- Attached to
- 27EHSSSYIGRANTHTKA: Grant Application for the SSYI Human Trafficking Intervention Program
- Solicitation number
- BD-27-1039-EHS01-EHS01-132905
- Issued by
- Massachusetts
About this file
This is a Contractor Authorized Signatory Listing (CASL) Form jointly issued by the Commonwealth of Massachusetts Office of the Comptroller and the Operational Services Division for use by all state departments unless otherwise specified by regulation or policy. The form is designed to establish authorized signatories for contractors, sole proprietors, and individuals who will execute contracts and legally binding documents on behalf of their organization with the Commonwealth. The required documentation includes a notarized signature of the authorized signatory, the contractor's legal name, vendor/customer code if available, the signatory's full legal name and title, and a notary certificate of acknowledgement. The form must be completed in the presence of a notary public who verifies the signatory's identity and confirms their authorization to sign on behalf of the contractor.
A completed copy of this CASL Form must be attached to the record copy of any contract filed with the relevant Commonwealth department. The Commonwealth reserves the right to publish the names and titles of authorized signatories as public record. Contractors are instructed not to attach any documentation containing personally identifiable information such as social security numbers, bank account numbers, driver's licenses, or home addresses. This form requirement applies to contractors responding to Commonwealth solicitations, including grant applications such as the SSYI Human Trafficking Intervention Program grant application issued by the Executive Office of Health and Human Services.
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Text version
Commonwealth of Massachusetts
CONTRACTOR AUTHORIZED SIGNATORY LISTING (CASL) FORM
This form is jointly issued and published by the Office of the Comptroller (CTR) and the Operational Services Division (OSD) as the default form for all Commonwealth Departments when another form is not prescribed by regulation or policy.
Notarized Signature for Individual, Sole-Proprietor or Single Member LLC (must match Form W-9 tax classification)
Contractor Legal Name Contractor Vendor/Customer Code (if available, not the Taxpayer Identification Number)
INSTRUCTIONS: Any Contractor, sole-proprietor, or an individual, must provide a notarized signature of the authorized person who can sign contracts and other legally binding documents related to the contract on the Contractor’s behalf.
For privacy purposes DO NOT ATTACH any documentation containing personal information, such as bank account numbers, social security numbers, driver’s licenses, home addresses, social security cards or any other personally identifiable information that you do not want released as part of a public record. The Commonwealth reserves the right to publish the names and titles of authorized signatories of contractors.
Signature (ink on paper) Contractor Signature as it will appear on contract or other documents (Complete only in presence of notary)
Print Signatory’s full legal name Title
Certificate of Acknowledgement of Notary Public Before me, the undersigned notary public, the above named individual proved to me through satisfactory evidence of identification, to be the person whose name is signed above and acknowledged to me that (he)/(she) signed for its stated purpose.
Print Notary Name Notary Signature (ink on paper)
Date My commission expires on
AFFIX NOTARY SEAL/STAMP
A copy of this document must be attached to the “record copy” of a contract filed with the department.
| Commonwealth of Massachusetts |
| CONTRACTOR AUTHORIZED SIGNATORY FORM |
| Contractor Legal Name: |
| Print Signatorys full legal name: |
| Title: |
| Date: |
| My commission expires on: |
| Contractor Vendor/Customer Code: |
| Print Notary Name: |
| AFFIX NOTARY SEAL/STAMP: |
File details come from the government source that posted it. Updated .